Provider Demographics
NPI:1336536697
Name:BRADDOCK, BRANDON (PA-C)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:BRADDOCK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 PEGGY PL
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-7199
Mailing Address - Country:US
Mailing Address - Phone:904-540-5454
Mailing Address - Fax:
Practice Address - Street 1:300 HEALTH PARK BLVD
Practice Address - Street 2:SUITE 4000
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-3707
Practice Address - Country:US
Practice Address - Phone:904-824-8666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-23
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108661363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant